OT 10211 MS PSYCH 2024 Anxiety Disorders PDF

Asst. Prof. Joselito Diaz, MD, MHA, FPNA, FPCPsych Cuellar, Delos Reyes, Garcia, Lim, Mendoza, Panganiban, Quitco De Jesus, Gayeta, Oblea, Pineda A., Salas, Victoria 2S3L: ANXIETY DISORDERS OUTLINE...

Asst. Prof. Joselito Diaz, MD, MHA, FPNA, FPCPsych Cuellar, Delos Reyes, Garcia, Lim, Mendoza, Panganiban, Quitco De Jesus, Gayeta, Oblea, Pineda A., Salas, Victoria 2S3L: ANXIETY DISORDERS OUTLINE E. Social Anxiety Disorder (Social Phobia) 9 I. Anxiety Disorders 1 F. Video Sample: Living with Social Anxiety 9 A. Etiology Of Anxiety Disorders 1 G. Treatment Of Phobia 9 B. DSM-IV-TR Versus DSM-V 2 IX. Generalized Anxiety Disorder 10 II. Normal Anxiety 2 A. Generalized Anxiety Disorder 10 A. Fear Versus Anxiety 2 B. DSM-5 Criteria For Generalized Anxiety Disorder 10 1. Fear 2 X. Separation Anxiety Disorder 10 2. Anxiety 2 A. DSM-5 Diagnostic Criteria For Separation B. Stress And Ego 2 Anxiety Disorder 10 C. Symptoms Of Anxiety 2 B. Video Sample: Maria (Separation Anxiety) 11 III. Anxiety Disorders 2 XI. Selective Mutism 11 1. Epidemiology 2 A. DSM-5 Diagnostic Criteria For Selective A. Etiology (Psychosocial Theories) 3 Mutism 11 B. Little Albert Experiment 3 B. Video Documentary: Dr. Max Gomez C. Etiology (Biological Theories) 3 (Selective Mutism) 11 IV. Panic Attacks 3 C. Sample Cases 12 A. Classifications 3 1. Unexpected Panic Attacks 3 ANXIETY DISORDERS Among the most prevalent mental disorders 2. Expected/Cued Panic Attacks 4 Characterized by both psychological and physical 3. Situationally Predisposed Panic Attacks symptoms. 4 ○ Difference between anxiety disorders and other B. Panic Attack Specifier (DSM-V) 4 psychiatric conditions Associated with significant morbidity C. Video Sample: Vlogger Having A Panic Attack ○ Chronic and recurrent 3 ○ Ex: Doc Diaz’ px with panic disorder V. Panic Disorders 4 He already treated in 2018 but was A. Epidemiology 4 discontinued medication due to the pandemic B. Panic Disorder Specifier (DSM-V) 4 Px is currently suffering again from anxiety despite being successful in his online C. Video Sample: Dealing With Anxiety And business during the pandemic Panic Attacks 5 Chronic and resistant to treatment D. Video Sample: A Panic Attack In A Coffee ○ Sometimes px would stop taking medications due to Shop 5 fear that they may become addicted/dependent on it VI. Panic Disorder 6 Manifestation of anxiety condition. Include: A. Course 6 ○ Panic disorder B. Treatment 6 ○ Agoraphobia 1. Pharmacotherapy 6 ○ Social phobia 2. Psychotherapy 6 ○ Specific phobia ○ Selective mutism C. How To Stop A Panic Attack? (Video) 6 ○ Separation anxiety disorder VII. Agoraphobia 7 ○ Generalized anxiety disorder (GAD) A. DSM-5 Criteria For Agoraphobia Social phobia and specific phobia ○ Most common among the psychiatric conditions B. Video Sample: Katy Meadows (Agoraphobia) 7 Selective mutism and separation anxiety disorder 7 ○ In children, may also be seen in adults VIII. Phobia 8 A. Specific Phobia 8 ETIOLOGY OF ANXIETY DISORDERS B. DSM-5 Diagnostic Criteria For Specific Phobia Interplay of genetic and experiential factors (nature vs 8 nurture) ○ Genetic: hereditary predisposition C. Social Phobia 9 Individuals with anxiety disorders have family D. DSM-5 Diagnostic Criteria For 9 members who also have anxiety disorders. 1  ANXIETY DISORDERS ○ Experiential: traumatic life events and stress STRESS AND EGO Onset of anxiety disorders are usually Perception of stress depends on the: precipitated by a traumatic/stressful event ○ Nature of the event ○ Person’s resources, psychological defenses DSM-IV-TR VERSUS DSM-V ○ Coping mechanisms It would vary from one individual to another depending on Table No. Anxiety disorders According to DSM-IV and V the person’s ego integrity and coping mechanism that DSM-IV-TR DSM-V will be utilized. Obsessive compulsive Panic disorder ○ Biopsychosocial model of anxiety disorder Dysfunctional ego results in anxiety Trauma and Generalized anxiety disorder ○ External conflicts: stress between the outside world stressor-related disorder and ego Changes in DSM-V Ex: Excessively demanding and critical boss ○ Obsessive compulsive disorder; trauma and ○ Internal conflicts: id versus superego stressor-related disorders were removed and would Ex: Aggressive impulses that must be have their own classification. controlled for fear of losing their job ○ Anxiety disorder remained to be the most prevalent Id: wanting to act upon aggression mental disorder. Superego: you might get fired Balancing → stress → anxiety NORMAL ANXIETY Everyone experiences anxiety SYMPTOMS OF ANXIETY Alerting signal Experience of anxiety has two components: ○ It warns of impending danger and enables a person ○ Awareness of the physiological sensations to take measures to deal with a threat (parasympathetic and too much adrenaline) Psychological symptoms Diarrhea, dizziness, lightheadedness, ○ Diffuse, unpleasant, vague sense of apprehension perspirations, hypertension, tachycardia, Autonomic symptoms palpitations, restlessness, pupillary dilatation, ○ Secondary to too much epinephrine or syncope, tingling in the extremities, tremors, norepinephrine upset stomach, and urinary frequency, ○ Headache, perspiration, palpitations, chest urgency and hesitancy tightness/discomfort, mild stomach discomfort, and ○ Awareness of being nervous or frightened restlessness, indicated as inability to sit or stand still (psychological component) for long. Feeling of shame may increase anxiety Signs and symptoms may vary among individuals Ex: Reporting in front of teachers and ○ Some may only experience palpitations and chest classmates. discomfort, while others may have abdominal Nervousness → shame as everybody is discomfort, frequent urination, or feeling that they are not nervous except you → increase going to faint anxiety. Life saving qualities Anxiety affects thinking, perception and learning ○ Warns of threats to bodily damage, pain, ○ Poor concentration, selective attention, etc. → helplessness, possible punishment, or the frustration increase anxiety of social or bodily needs ○ Ex: Preparing for examination ○ Prompts a person to take the necessary steps to Anxious → poor concentration → cannot pick prevent the threat or to lessen its consequences up or memorize → perpetuate anxiety. Accompanied by somatic and autonomic activity/hyperarousal ANXIETY DISORDERS ○ May be an interaction between the sympathetic and parasympathetic nervous systems EPIDEMIOLOGY Sympathetic nervous system predominantly Ex: frequent urinations One of 4 persons met the diagnostic criteria for at least Parasympathetic nervous system one anxiety disorder Ex: going to the bathroom to evacuate 1 year prevalence rate of 17.7% as if they have loose bowel movement Prevalence reduces with higher socioeconomic status ○ More financial capacity = less anxiety FEAR VERSUS ANXIETY ○ One of the reason for anxiety is the social factor FEAR Response to a known/actual, external, definite, or non conflictual threat Ex: rapidly approaching car as a person crosses the street ANXIETY Response to a threat that is unknown, internal, vague, or conflictual Lifetime prevalence Sense of apprehension: anticipation of a possible threat ○ Female: 30.5% (more common) Ex: meeting new persons in a strange setting ○ Male: 19.2% 2  ANXIETY DISORDERS ○ Social phobia: rate is almost the same in females ETIOLOGY (BIOLOGICAL THEORIES) and males Autonomic Nervous System ○ Increased sympathetic tone, adapt slowly to ETIOLOGY (PSYCHOSOCIAL THEORIES) repeated stimuli, and respond excessively to Psychoanalytic Theory moderate stimuli → physical symptoms ○ Result of psychic conflict between unconscious Neurotransmitters sexual or aggressive wishes and corresponding ○ Norepinephrine threats from the superego or external reality Poorly regulated noradrenergic system with Ego dysfunction occasional burst of activity ○ Mobilization of the ego defenses Stimulation of the locus cereleus produces a Ego is not able to control the anxiety by fear response mobilizing the defense mechanism → anxiety ○ Serotonin ○ Unsuccessful defense against anxiety-provoking Therapeutic effects of serotonergic impulses antidepressants in anxiety disorders Cognitive-Behavioral theories ○ GABA ○ Conditioned response to a specific environmental Efficacy of benzodiazepines, an agonist of stimulus GABAA in the treatment of anxiety disorders Classical or operant conditioning Abnormal functioning of GABAA receptors ○ Imitating the anxiety in the environment, such as in ○ Norepinephrine and serotonin anxious parents Improvement due to antidepressants in Ex. A child is not afraid of rats. But if he sees controlling anxiety that his older siblings or parents are afraid of Neuroimaging correlates rats, he may imitate the behavior. ○ Possible neuroanatomical correlates of anxiety ○ Limbic system and cerebral cortex LITTLE ALBERT EXPERIMENT ○ Pathological involvement of the temporal lobes, John B. Watson, demonstrated classical conditioning particularly the hippocampus and amygdala in panic empirically through experimentation using the Little Albert disorders experiment ○ Lower metabolic rate in basal ganglia and white ○ A child ("Albert") was presented with a white rat to matter in patients with GAD play with, which was later paired with a loud noise Genetic studies ○ As the trials progressed, the child began showing ○ Interplay between nature and nurture signs of distress at the sight of the rat and other Nature: already a genetic predisposition white objects, demonstrating that conditioning had ○ Higher frequency of anxiety disorders in first degree taken place relatives of affected patients ○ Unethical experiment ○ Higher concordance rate in monozygotic than in Subjecting the infant to probable misery as he dizygotic twins grows older ○ Polygenic transmission Proved that conditioning can be a reason for Several, [general] genes involved the development of anxiety (specific and No particular gene locus to determine risk for social anxiety) anxiety Conditioning: can be a possible cause of phobia ○ Implications: know better treatment for this condition PANIC ATTACKS Intense attack of anxiety accompanied by feelings of impending doom ○ Occur also in other anxiety disorders such as PTSD, social and specific phobias ○ May occur in other psychiatric (depression with anxious distress), psychotic, and medical conditions (substance withdrawal or intoxication) ○ Impending doom: going to die, having a serious medical condition, going crazy Begins with a 10-minute period of rapidly increasing symptoms ○ Crescendo (1 hour which he would play with without fear ○ Crescendo by 10 minutes and then plateau ○ If a steel bar was hit by a hammer (loud noise) → ○ Usually lasts for around 30 minutes Albert would automatically cry (fear/anxiety) Symptoms can disappear quickly or gradually During conditioning ○ Usually disappears slowly ○ White rat was presented and was paired with a loud noise → Albert would cry (fear) CLASSIFICATIONS After conditioning ○ Albert would cry (fear) when presented with white rat even without loud noise UNEXPECTED PANIC ATTACKS ○ Other white objects would also cause distress to Occur at any time and not associated with any identifiable Albert (generalization) situational stimulus Panic attack for no apparent reason 3  ANXIETY DISORDERS More troubling as there would be sudden palpitation, COMMENTARY difficulty breathing, chest tightness, hyperventilate, trembling, feeling of losing consciousness, spasms of Talking about his anxiety → brings shame → panic attack hands of feet d/t hypocapnia → thinking if they are having How he dealt with the panic attack panic attack, stroke, death ○ Controlled breathing, SMRT ○ Usually brought to emergency room ○ Cognitive therapy: I had this panic attack before, I am not having a heart attack, I am not going to die. EXPECTED/CUED PANIC ATTACKS PANIC DISORDERS Panic attacks are generally unexpected Associated with a recognized or specific stimulus First attack is often completely spontaneous ○ Social and specific phobias Panic attacks vary from several attacks per day to a few Panic attack upon presentation of feared object/situation attacks per year ○ Ex: claustrophobic – a lot of people in the elevator → Somatic concerns of death from a cardiac or respiratory panic attack. problem ○ Palpitation and chest pain SITUATIONALLY PREDISPOSED PANIC ATTACKS ○ Physically healthy young adults insisting they are going to die from a heart attack (common) May or may not occur when the patient is exposed to a If no known problems after visiting several specific trigger specialists (cardiac, gastrointestinal, May occur immediately or after a considerable delay pulmonary problems) → refer to psychiatry ○ Syncopal attack PANIC ATTACK SPECIFIER (DSM-V) Dizziness, unsteadiness, lightheadedness, An abrupt surge of intense fear or intense discomfort feeling of losing consciousness that reaches a peak within minutes, and during which four In between attacks, patients may have anticipatory (or more) of the following symptoms occur anxiety about having another attack ○ The abrupt surge can occur from a calm state or an anxious state. EPIDEMIOLOGY (1) Palpitations, pounding heart, or accelerated heart Lifetime prevalence: 1-4% rate (tachycardia) Women 2-3x more likely to be affected (2) Sweating (cold sweats) Most commonly develops in young adulthood (3) Trembling or shaking ○ Mean age: 25 years (4) Sensations of shortness of breath or smothering 91% of patients have at least one other comorbid (5) Feeling of choking psychiatric disorder Parang may nakabara sa lalamunan ○ 2-10%: PTSD (6) Chest pain or discomfort ○ 2-20%: specific phobia (7) Nausea or abdominal distress ○ 10-15%: major depressive disorder (8) Feeling dizzy, unsteady, light-headed, or faint ○ 15-30%: social phobia (9) Chills or heat sensations ○ 15-30%: generalized anxiety disorder (10) Paresthesias (numbness or tingling sensations) ○ ~30%: OCD (11) *Derealization (feelings of unreality) or ○ Others: substance-related disorders (to cope and Depersonalization (being detached from oneself) calm down), personality disorders, hypochondriasis (12) *Fear of losing control or “going crazy” (13) *Fear of dying PANIC DISORDER SPECIFIER (DSM-V) ○ * Signs of impending doom, psychological symptoms A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that VIDEO SAMPLE: VLOGGER HAVING A PANIC reaches a peak within minutes, and during which time four ATTACK (or more) of the following symptoms occur: He has been suffering from anxiety since he was 14 or 15 ○ The abrupt surge can occur from a calm state or an but he does not know why. anxious state. He suddenly seems distraught but tries to calm himself (1) Palpitations, pounding heart, or accelerated heart down by taking deep breaths with his hand on his chest. rate (tachycardia) He says that “he thinks he’s having a heart attack” and his (2) Sweating (cold sweats) breathing became heavier and more shallow, with feeling (3) Trembling or shaking of choking (4) Sensations of shortness of breath or smothering He reminds himself to breathe, to slow down his breathing, (5) Feeling of choking think normally and with happy thoughts, and he’s not Parang may nakabara sa lalamunan having a heart attack. (6) Chest pain or discomfort He tries to get some air by putting his hands on his nape (7) Nausea or abdominal distress He was able to calm down and explained that he thinks he (8) Feeling dizzy, unsteady, light-headed, or faint had a severe panic attack because he talked about his (9) Chills or heat sensations past, his anxiety, and how it affected him. (10) Paresthesias (numbness or tingling sensations) Thinking about these things started to worry him because (11) *Derealization (feelings of unreality) or he did not want to talk about it in front of a camera. Depersonalization (being detached from oneself) He actually thought he was having a heart attack due to (12) *Fear of losing control or “going crazy” chest pains and palpitations, but because he’s had panic (13) *Fear of dying attacks before, he knew that it was not a heart attack. ○ * Signs of impending doom, psychological symptoms Thus, he told himself to breathe, think happy thoughts, B. At least one of the attacks has been followed by 1 month and reassure himself that this is just a panic attack and not (or more) of one or both of the following: a heart attack to feel less anxious and panicky 4  ANXIETY DISORDERS (1) Persistent concern or worry about additional panic She remembers an aunt that experienced panic attacks attacks or their consequences but never really understood what that meant and never Anticipatory anxiety: losing control, having a imagined it felt as scary as what she just went through heart attack, “going crazy” Nothing is physically wrong and she checks out of the (2) A significant maladaptive change in behavior related hospital and goes home to the attacks (e.g., behaviors designed to avoid Within minutes of lying on the bed she falls fast asleep having panic attacks, such as avoidance of exercise On waking the following day, Jane immediately begins to or unfamiliar situations). go over the ordeal in her mind Avoidance behaviors It all seems like a surreal dream and by lunchtime she is C. The disturbance is not attributable to the physiological already second-guessing the medical tests and convinces effects of: herself that something was missed and that there must be ○ A substance: drug of abuse, a medication something more serious than anxiety involved ○ Another medical condition: hyperthyroidism, Days pass and she cannot stop thinking about what cardiopulmonary disorders happened in the supermarket D. The disturbance is not better explained by another mental She stills feels shaken by the experience and lives in fear disorder. Panic attacks do not occur only in response to: that it might strike her again at any moment ○ Feared social situations: social anxiety disorder For the first time in her life she does not feel safe leaving ○ Circumscribed phobic objects or situations: specific her home phobia ○ Obsessions: obsessive compulsive disorder ○ Reminders of traumatic events: posttraumatic stress COMMENTARY disorder Jane had an unexpected panic attack which did not last for ○ Separation from attachment figures: separation a long time as she was feeling better when she was anxiety disorder leaving the supermarket She went to the hospital and find out nothing is wrong with VIDEO SAMPLE: DEALING WITH ANXIETY AND her, except for the panic attack and was sent home PANIC ATTACKS She remembered her aunt who had panic attack before Jane has just left work and was in the supermarket doing She felt better but she was questioning the result as the her weekly shopping day passed by She's got a lot of things on her mind and has been rushing Diagnostic Criteria for Panic Disorder (DSM-V) around throwing all the items into the shopping cart ○ Doubt of having another medical condition, fearful of While checking the price on a can of goods she notices having another, maladaptive behavior (afraid of something strange leaving the house) Her heart has suddenly began to beat hard that it is pulsating in her throat VIDEO SAMPLE: A PANIC ATTACK IN A COFFEE This startles her and then she notices how her arm begins SHOP to shake with a pins and needles sensation Jane was invited to have a coffee after work with her This is the first time anything like this has ever happened colleague Lisa. to her Five weeks ago, she experienced her first panic attack She is confused and starting to get really scared and since then has been in a state of general anxiety Something must be wrong she thinks and begins to She feels anxious and uptight throughout the day and mentally list all the possible things it could be frequently fears the arrival of another panic attack ○ ‘Is it the start of a heart attack, She is shied away from social events since her first panic ○ Is this an allergic reaction to something she ate’ attack Her stomach and chest muscles feel really tense and her Scoring anxiety on a scale of 1 to 10 where one breathing becomes faster and more shallow represents complete relaxation and 10 total panic She glances around at the people near her and as she ○ Jane: currently hovering around the 5 mark does so she feels a light-headed and dizzy ○ Lisa: feeling much more relaxed at around 3 (normal The confusion and fear she feels sends her into a panic level of daily stress) The sensations in her body intensify and she's convinced Red ball around Jane's stomach something awful is about to happen ○ Signifies the general anxiety Jane is feeling She feels a need to get outside and leaves her shopping She tries to follow the conversation with her colleague but cart behind as she walks slowly towards the exit cannot stop thinking about the anxiety and begins to feel As soon as she is outside in the cool air, she feels a slight more uncomfortable sitting in the busy cafe sense of relief and more in control as the physical She feels her unease grow stronger and thinks about sensations are losing momentum excusing herself to go home early Although she is calming down, she is still in shock and her ○ Her heart suddenly skips a beat and starts pounding body is shaking really hard, that she can feel it beat in her throat It feels as if someone had just held a gun to her head ○ Exactly the same as what happened when she had a She has never felt so terrified and out of control all her life panic attack in the supermarket and she reacts with She calls her husband at work and tells him what fear to the sensation happened and asks if he would meet her so they can go to ‘What will she do if she has a panic attack here in front of the hospital together her colleague?’ A few hours later, Jane is lying on the hospital bed waiting ○ The fearful reaction she is having to the sensations for the results of the medical tests she has completed sends another bolt of panic through her body to her The doctor arrives and tells her they cannot find anything ○ It feels as if an internal bomb has just been primed physically wrong with her and that it was most likely a and is about to explode panic attack ○ Very terrifying for her and it just came out of nowhere This is relieving yet confusing at the same time like the last time 5  ANXIETY DISORDERS She feels trapped sitting at the table and excuses herself Respiratory training by standing up ○ Control urge to hyperventilate She does not want her colleague to know that something Controlling breathing and not might be wrong hyperventilate Each sensation she feels in her body causes a shock wave of panic to pass through her HOW TO STOP A PANIC ATTACK? Jane fears that the experience will intensify to the point of (VIDEO) no return Example of a behavioral cognitive treatment to control She is reaching the climax of her panic attack and it is a anxiety: moment of sheer terror for her ○ YouTube Link: Her heart is pounding fast her breathing feels restricted https://www.youtube.com/watch?v=0P8f4ExY3v and she feels dizzy and fears she might faint s The feeling is so terrifying Jane fears her very life is in danger 1. Start by reminding yourself that this is an episode of anxiety. It is not harmful and that you have experienced it COMMENTARY many times before. You should not get upset with the sensation that you are feeling and should respond to the Jane has recurrence of panic attacks situation with a new understanding: Build up (crescendo) within minutes and would peak within “This is nothing more than heightened bodily the 10th minute mark sensations. I am not in any danger or Anticipatory anxiety: always worried of having another whatsoever.” panic attack 2. OBSERVE: Begin observing the sensations (e.g., heart is Usually they would build up within minutes (crescendo) beating fast; chest tightening). Initial reaction is to pull and would peak within the 10th minute mark away and suppress the sensations of anxiety but decide Anticipatory Anxiety: Belief that they are having a major that rather than closing down, you should let the medical or psychiatric problem (e.g., going crazy, having a sensations run though your body and process this fear. Be heart attack) aware that this will take courage and maybe an ○ Ex.: The patient in the video is worried that she uncomfortable exercise but know that you must travel will have another panic attack again through the anxiety to be fully free of it. ○ If anticipatory anxiety has been lasting for a 3. Start observing the flow of the anxiety as it rises and flows month or there is already a maladaptive behavior in the body. Then, start to embrace it with all your heart then it is already a panic disorder and mind by welcoming the increased anxiety and unusual sensations. This act of welcoming changes your position PANIC DISORDER of power. As soon as you change your attitude towards the sensations, you will automatically flow with the experience. COURSE There will be an immediate bodily change as you mentally Course is chronic and variable move with the panic instead of suppressing it. You should ○ Long term follow-up allow the sensations that you feel to be there and to move 30-40% symptom free and manifest any way they wish. 50% mild symptoms (majority) This new attitude is vital because the fear must 10-20% significant symptoms be processed with the body and mind and not ○ Frequency and severity of attacks can fluctuate be suppressed. ○ Poor prognosis: Comorbid depression, substance 4. EMBRACE: As you embrace and welcome the dependence, OCD, suicidal ideations sensations, the heart beats even louder and you will be feeling a pounding on your throat, chest, and stomach. TREATMENT Feelings of anxiety are now being processed and you may even feel a sense of heat or hot flush. This is not a feeling of calm or tranquil moment. It is an intense feeling. It is at PHARMACOTHERAPY this juncture of heightened bodily sensations that you will implement the final phase. SSRIs, benzodiazepines, tricyclic antidepressants 5. DEMAND MORE: Make a direct request to the body and ○ The problem with benzodiazepines is that they mind for more (more panic, more pain). This is the crucial may develop tolerance to the medication. But in mood that is needed to ensure success and fully process order to quell the physical symptoms, the fear that you are feeling. benzodiazepines are very effective. By demanding more, you will be able to remove every last bit of resistance that you were PSYCHOTHERAPY creating mentally. The fear is fully allowed to pass through. The cycle of panic stops because Cognitive therapy you are no longer feeding the fear with mental ○ Panic attacks are time limited and not life resistance instead you are demanding that if threatening there is really something going to go wrong, Convincing yourself that you have then it will happen right now, stopping all the experienced this before and that you are drama of building up to it. only having a panic attack and not a The fearful experienced is now fully processed heart attack through the body and mind without resisting. By Applied relaxation not resisting anymore, there is no further rebound ○ Techniques of muscle relaxation and the anxiety and no cycle of panic. imagining of relaxing situations The immediate benefit is that your confidence “Good thoughts” begins to soar. You are now coming to 6  ANXIETY DISORDERS understand that you can in fact control this I. The fear, anxiety, or avoidance is not better explained by the experience that up until now she felt was symptoms of another mental disorder uncontrollable. For example: the symptoms are not confined to ○ You are now participating with the flow specific phobia, situational type; of bodily sensations and you now finally do not involve only social situations (as in social understand the role that you could play anxiety disorder): by allowing the experience to flow ○ are not related exclusively to obsessions (as through you rather than resisting it. in obsessive compulsive disorder) You may always had the power to dictate how a ○ perceived defects or flaws in physical panic attack would develop but you should have appearance (as in body dysmorphic these specific psychological tools to do so. disorder) ○ reminders of traumatic events (as in AGORAPHOBIA posttraumatic stress disorder) Patient with panic disorder usually has a comorbid ○ fear of separation (as in separation anxiety agoraphobia (may or may not have) disorder). ○ translated from Greek term meaning “fear of the marketplace” VIDEO SAMPLE: KATY MEADOWS (AGORAPHOBIA) fear of venturing alone in public Here is a video of an individual with Agoraphobia. places Again, it is fear of leaving house alone or being in a ○ Fear of having a panic attack in a public place crowded place or a case where help may be from which escape might be difficult unavailable. ○ Rigid avoidance of situations in which it would be YouTube Link: difficult to obtain help https://www.youtube.com/watch?v=HvOsFSz73ew ○ Prefer to be accompanied every time they leave the house KATY: It is not helpful when people tell me that outside is safe ○ Simply refuse to leave the house and fun. A lot of me who have disorders do not have a logic to them because I'm pretty aware that it’s pretty missed up to not DSM-5 CRITERIA FOR AGORAPHOBIA leave the house. My name is Kattie Meadows, I’m 26b years A. Marked fear or anxiety about two (or more) of the old. following five situations: 1. Using public transportation (e.g., automobiles, buses, Agoraphobia is a subset of panic disorder. It is not a fear of trains, ships,planes). going outside but I have a fear of being in a situation where I a. Because of the fear that escape may be have panic attacks. If I go outside, I don’t have control of the difficult situation unlike in my house or in my room, I can control my 2. Being in open spaces (e.g., parking lots, environment. I can control who comes into my house and who marketplaces, bridges). doesn’t. I can simply surround myself with things that I like. a. Because of the fear that help may not be This is my room. This is my safe space and I fill it with things available that make me feel safe and happy. Over here are my aliens, a 3. Being in enclosed places (e.g., shops, theaters, photo of my friend Emma who met Justin Bieber, and a worry cinemas). department photo. I have a lot of intrusive thoughts. That's a. Because of the fear that help may not be when your brain does things to you that are unnecessarily real available and escape might be difficult but it is just the thought like you be walking pass the bridge 4. Standing in line or being in a crowd. and it might be like jumping off it. 5. Being outside of the home alone. B. The individual fears or avoids these situations because When I go outside, I tend to have a lot of intrusive thoughts – of thoughts that escape might be difficult or help might walking on the street, you could run into the traffic and the idea not be available in the event of developing panic-like of thinking that before going outside puts me off wanting me to symptoms or other incapacitating or embarrassing symptoms do it means that I will be in a state of anxiety. I have impending (e.g., fear of falling in the elderly; fear of incontinence) scenes of doom that I’m about to die and everything is about to They try to avoid two or more of the situations die wherein I cannot do anything about it at all. I just sort of risk because of the fear that escape might be difficult and the most skid primitive version of myself and I just can't help might not be available if they have panic-like process anything around me. symptoms. C. The agoraphobic situations almost always provoke fear or Because I know how intense panic attacks are, especially anxiety. because I have the whole time and it enabled my current D. The agoraphobic situations are actively avoided, require the phobia because of my need to protect myself from feeling that presence of a companion, or are endured with intense fear or way. I also have PTSD from sexual assaults and I think that anxiety. has a lot to do with it as well. The feeling when you go outside E. The fear or anxiety is out of proportion to the actual danger at night and I hope nothing happens and I hope this is fine. posed by the agoraphobic situations and to the sociocultural That’s how I kind of feel when I am outside. context. F. The fear, anxiety, or avoidance is persistent, typically lasting It mainly feels like “okay go to a suburb or a supermarket”. I for 6 months or more. flew to Oakland recently and I had to have friends chaperoning G. The fear, anxiety, or avoidance causes clinically me on the plane, chaperoning me while I was there, and significant distress or impairment in social, occupational, or chaperoning me on the way back because the last time I went other important areas of functioning. to Oakland which was for a funeral , I had been there for like H. If another medical condition (e.g., inflammatory bowel half an hour and had a 5-hour panic attack and I had to get a disease, Parkinson’s disease) is present, the fear, anxiety, or prospect and I miss the funeral. I’m really into celebrities and avoidance is clearly excessive. meeting them. This is me and Greg Sestero who played Mark “In the room”. This is a rose that Boomer gave me the other 7  ANXIETY DISORDERS week and I have my tattoo of him and he touched it and gave me this rose. PHOBIA Excessive fear of a specific object, circumstance, or I like creating something to completion, especially because I situation cannot do a lot of traditional jobs or anything, so with that, it’s Specific phobia: strong persistent fear of an object or like one of my control. One of the things that helped was going situation into therapy, like I am on the benefit and that’s how I had fun ○ Height, animals, blood doing these things. Honestly the most helpful thing for me is ○ Anticipate harm or fear of losing control the support of people. Just like believing that when i say, “im Social phobia (social anxiety disorder): strong, persistent worried about going outside because i dont wanna have panic fear of situations in which embarrassment can occur attacks i feel like that's fine, what can we do instead. ○ Performance or generalized One of the most common mental disorder This is an autograph from Jonny Fairplay. He was on survivor ○ Lifetime prevalence of specific phobia: 11% and he was famous for planning ahead of time to lie and say ○ Lifetime prevalence of social phobia: 3-13% that his grandmother died so that people feel sorry for him and he wrote “To: Katy, I never lie” which is a lie. SPECIFIC PHOBIA Most common mental disorder in women; 2nd in men (1st This small bag of teeth– i had to get my wisdom teeth out but in men: substance-related disorders) they messed it up and went into septic shock and nearly died, Types: so i kept my teeth. ○ Animal type ○ Natural environment type (e.g. heights, storms, The difference between someone who’s being a recluse and water) someone who’s actually suffering agoraphobia is that I ○ Blood-injection-injury type differently had like innate and a want to be a part of society. Its ○ Situational type (e.g. airplanes, elevators, not like I'm choosing to shut myself up, I would never have this enclosed spaces) by choice and I think a lot of people think that I'm lazy or I don't ○ Other type (e.g. fear of choking, vomiting, or like going out and doing things. In the future, I just wanna go contracting an illness; in children, fear of loud out, I wanna go on like a road trip, I wanna go to japan. I sounds or costumed characters) actually have this recurring agoraphobia nightmare wherein i Descending frequency: animals, storms, heights, finally get to go to japan and I finally travel and I get there and i illness, injury and death can't leave the hotel, I'm stuck in the hotel walking around in Panic attack is situationally bound to the specific phobic circles because I'm too scared to go out and I find out that my stimulus time is up and I have to fly back and I’ve just missed everything Cause: conditioning and i have that dream twice a week. Natural environment type is most common in children